Spravato (esketamine) Letter of Medical Necessity
Spravato (esketamine) requires REMS-certified administration and documented treatment-resistant depression. PAs require detailed prior treatment history.
FDA-Approved Indications
- ● treatment-resistant depression
- ● major depressive disorder with acute suicidal ideation
Why Spravato Prior Authorization Gets Denied
The most common denial reasons across major payers:
- 1. Two antidepressant trials not documented
- 2. REMS center enrollment missing
- 3. Severity scoring missing
What to Include in a Spravato Letter of Medical Necessity
Document MDD diagnosis with severity (PHQ-9, MADRS), at least two adequate antidepressant trials with dose/duration/outcome, REMS enrollment, and the planned monitoring protocol.
Key clinical evidence to cite:
- ✓ TRANSFORM-1, -2, -3, SUSTAIN-1, ASPIRE I & II
Relevant guidelines:
- 📖 APA Depression Practice Guideline
Spravato Prior Authorization Criteria
Standard criteria across major US payers for Spravato. Specific criteria vary by plan — RxCheckUp tailors each LMN to your patient's exact payer policy.
Typical step therapy requirements:
- → Two antidepressant trials not documented
Required documentation:
- ✓ ICD-10 diagnosis code with specificity
- ✓ Prior therapy history with dates, doses, and discontinuation reasons
- ✓ Specialist evaluation (where applicable)
- ✓ Baseline disease activity or biomarker results
- ✓ Clinical rationale citing FDA labeling or guidelines
Approval details:
Initial approval: typically 6 months. Renewal: 12 months with documented clinical response.
Payers Covering Spravato
RxCheckUp tailors each LMN to the specific payer's medical policy and step therapy requirements:
Spravato Prior Authorization FAQ
Why was my Spravato prior authorization denied?
The most common denial reasons for Spravato are: Two antidepressant trials not documented; REMS center enrollment missing; Severity scoring missing.
What should a Spravato Letter of Medical Necessity include?
Document MDD diagnosis with severity (PHQ-9, MADRS), at least two adequate antidepressant trials with dose/duration/outcome, REMS enrollment, and the planned monitoring protocol.
Which payers cover Spravato?
Spravato is covered by major US payers including UnitedHealthcare, Aetna, Cigna, BCBS, Medicare Part D, though formulary tier and prior authorization criteria vary.